Intraoperatively discovered injury
Careful inspection may reveal no leakage or bleeding in the affected area. Small punctures or superficial lacerations seal readily and may not require further treatment (FIGURE 2B), but larger perforations require repair. Straightforward repair is not always possible when the injury is extensive and considerable time has elapsed before it is discovered.
Inspect the intestine thoroughly at the conclusion of a procedure; obvious leakage requires intervention. Repair the small intestine in one or two layers, using the initial row of interrupted sutures to approximate the mucosa and muscularis.24 To lessen the risk of stenosis, close all lacerations transversely when they are smaller than one half the diameter of the bowel. If the laceration exceeds that size, segmental resection and anastomosis are necessary. Resection is prudent if the mesenteric blood supply is compromised.25
When performing one-layer repair of the small bowel, delayed absorbable suture (eg, Vicryl or PDS) or nonabsorbable suture (eg, silk) is recommended.26
At the conclusion of a repair, copiously irrigate the entire abdomen. Place a nasogastric tube only if ileus is anticipated; the tube can be removed when drainage diminishes and active bowel sounds and flatus appear. Do not give anything by mouth until the patient has return of bowel function and active peristalsis. Prescribe prophylactic antibiotics.
Note that peritonitis sometimes develops after repair of the bowel.25 This can be managed with prolonged bowel rest and peripheral or total parenteral nutrition.
Conservative management may be possible
Patients whose symptoms of bowel laceration become apparent after discharge can sometimes be managed conservatively. More than 50% of patients treated conservatively require no surgery.23 Inpatient management consists of monitoring the WBC count, providing hydration and IV antibiotics, and examining the patient every 6 hours, giving nothing by mouth.
When injury is discovered later
If conservative management with observation and bowel rest fails, or the patient complains of severe abdominal pain, vomiting, nausea, obstipation, or signs and symptoms of peritonitis, such as the patient in Case 3, immediate surgical intervention is necessary. When an injury is not detected until some time after initial surgery, resection of all necrotic tissue is mandatory. In most cases, the perforation is managed by segmental resection and reanastomosis. Evaluate the entire small and large bowel to rule out any other injury, and irrigate generously. Bowel rest, parenteral nutrition, and IV antibiotics also are indicated.
Of 36,928 procedures reported by members of the American Association of Gynecologic Laparoscopists, there were two deaths—both caused by unrecognized bowel injury.15
CASE 4: Large-bowel injury precipitates lengthy recovery
A surgeon performs a left laparoscopic salpingo-oophorectomy to remove an 8-cm ovarian endometrioma that is adherent to the rectosigmoid colon of a 40-year-old diabetic woman. Sharp and electrosurgical scissors are used to separate the adnexa from the rectosigmoid colon. No injury is observed, and she is discharged the same day. Four days later, she returns with severe abdominal pain, nausea, vomiting, and fatigue. Lab tests reveal a WBC count of 17,000; a CT scan shows pockets of air beneath the diaphragm, as well as fluid collection suggestive of a pelvic abscess.
Immediate laparotomy is performed, during which the surgeon discovers contamination of the abdominal viscera by bowel contents, as well as a 0.5-cm perforation of the rectosigmoid colon. The perforation is repaired in two layers after its edges are trimmed, and a diverting colostomy is performed. The patient is admitted to the ICU and requires antibiotic treatment, total parenteral nutrition, and bowel rest due to severe peritonitis. She gradually recovers and is discharged 3 weeks later. The diverting colostomy is reversed 3 months later.
Even small perforations in the large bowel can cause infection and abscess due to the high bacterial content of the colon. The most common cause of injury to the rectosigmoid colon is pelvic adhesiolysis during cul-de-sac dissection, treatment of pelvic endometriosis, and resection of adherent pelvic masses.
Sharp dissection with scissors or high-powered lasers is relatively safe near the bowel. When dissecting the cul-de-sac, identify the vagina and rectum by placing a probe or finger in each area. Begin dissection from the unaffected pararectal space, and proceed toward the obliterated cul-de-sac.27,28
Bowel prep is indicated before extensive pelvic surgery and when the history suggests endometriosis or significant pelvic adhesions. Some general surgeons base their decision to perform colostomy (or not) on whether the bowel was prepped preoperatively.29
If the large bowel is perforated by the Veress needle, the saline aspiration test will yield brownish fluid. When significant pelvic adhesiolysis or pelvic or endometriotic tumor resection is performed, inject air into the rectum afterward via a sigmoidoscope or bulb syringe and assess the submerged rectum and rectosigmoid colon for bubbling. The rectal wall may be weakened during these types of procedures, so instruct the patient to use oral stool softeners and avoid enemas.30